Specialty Care Access in the Community Health Center Setting

&The APMA/TDI Public Health Fellowship

Dyane E. Tower, DPM, MSMPH Candidate

The Dartmouth Institute of Health Policy & Clinical Practice

Young Physician’s InstituteFranklin, TN – April 13, 2013

Objectives

• Discuss the role of community health centers (CHC).

• Discuss specialty care access in CHC setting.

• Explore the APMA/TDI Public Health Fellowship.

• Tie it all together. Source: www.nachc.com

Community Health Center

• Designed to reduce disparities• Minority groups

• Poor

• Under- & uninsured

• Provide:• Safety net

• Care for disadvantaged populations

Source: www.nachc.com

CHCs

• Medical home to ~5% of US population

• Deliver care to ~20 million people

Source: www.scfhc.org

Medicaid Expansion

• Health insurance exchanges become established• Increase percentage of Americans using CHC services

• Concern with CHC capacity• Specialty care

Source: www.healtheconomists.blogspot.com

Specialty Care Access

• Off-site medical specialty care• Difficulties accessing care

• Poorer outcomes

• What about surgical specialties?• Podiatry

Source: www.equity.lsnc.net

APMA/TDI Public Health FellowshipMentor: James J. DiResta, DPM, MPH

Est. 2012 – 2013 Academic Year

APMA/TDI Public Health Fellowship

• Offers fundamental skills, knowledge base and philosophical foundation in health policy and clinical practice• Specific attention paid to:

• Public health

• Clinical/health services research

• Healthcare leadership

The Dartmouth Institute

• Founded in 1988• Center for the Evaluative Clinical Sciences • Dr. John E. Wennberg, MD, MPH• Housed within the Department of Community &

Family Medicine at Geisel School of Medicine at Dartmouth

• In 2007 TDI reorganized as independent entity

• Current Director: Dr. Elliott Fisher, MD, MPH

http://www.tdi.dartmouth.edu/

TDI Centers

• Health Policy Research

• Informed Choice

• Leadership & Improvement

• Medicine & the Media

• Aging Research

• Education

• Population Health

Coursework

• General Public Health• Strategic & Financial Management of Health Care

Institutions

• Critical Issues in Health & Health Care

• Social & Behavioral Determinants of Health

• Practical Approaches for Today’s Health Care Ethics Challenges

• Environmental Health Science & Policy

Coursework

• Analytic Courses• Epidemiology/Biostatistics 1

• Part 1

• Part 2

• Epidemiology/Biostatistics 2

• Advanced Methods in Health Services Research

• Decision & Cost-Effectiveness Analysis

Coursework

• Quality Improvement• Continual Improvement of Health Care

• Statistical Measurement & Analysis in Quality Improvement

• Design & Improvement of Clinical Microsystems

Coursework

• Research Methods• Inferential Methods & Systematic Review

• Part 1

• Part 2

• Qualitative Methods Toolbox

• Current Status of Practice Variation Research

Tools

How it all ties together…

• MPH Capstone• Improving access to a community health center’s

podiatric specialty clinic: A quality improvement project with a clinical microsystems approach

Patients with podiatric needs are seen by PCP

Referral from PCP to podiatry

Referral in EMR goes to Shirley

List of podiatry referrals goes to podiatry MA

Podiatry MA decides where to put

patient on referral list based on condition

Patient waits on referral list based on condition

Podiatry MA schedules patient for clinic

Patient is seen in podiatric specialty

clinic

Activities

New England

Questions?Thank you.

Dr. Dyane Tower, DPM, MS & Dr. Elliott Fisher, MD, MPH

References

Adashi EY, Geiger HJ, Fine MD. Health care reform and primary care—the growing importance of the community health center. New England Journal of Medicine 2010;362:2047-50.

Cook NL, Hicks LRS, O’Malley AJ, Keegan T, Guadagnoli E, Landon BE. Access to specialty care and medical services in community health centers. Health Affairs 2007;26:1459-68.

Landon BE, Hicks LRS, O'Malley AJ, et al. Improving the management of chronic disease at community health centers. New England Journal of Medicine 2007;356:921-34.

Felt-Lisk S, McHugh M, Howell E. Monitoring Local Safety-Net Providers: Do They Have Adequate Capacity? Health Affairs 2002;21:277-83.

Gusmano MK, Fairbrother G, Park H. Exploring The Limits Of The Safety Net: Community Health Centers And Care For The Uninsured. Health Affairs 2002;21:188-94.

Hurley R, Felland L, Lauer J. Community health centers tackle rising demands and expectations. Issue Brief Cent Stud Health Syst Change 2007;116:1-4.

Neuhausen K, Grumbach K, Bazemore A, Phillips RL. Integrating Community Health Centers Into Organized Delivery Systems Can Improve Access To Subspecialty Care. Health Affairs 2012;31:1708-16.